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SAN p Environmental Health Department U- 41 ` —COUNTY-- - Greatness grows here RIMMED SITE MITIGATION WELL & BORING PERMIT APPLICATION NOV 0 9 1017 For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED €NVIRONMk T Ham? 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made In comp lance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards Job Address 2222 S. Airport Way CitylStatelZip Stockton, CA, 95202 Phone Cross Street E 8th Street APN 169-163-01 Propertyowner' Cly, of Stockton Phone 209-937-8309 Address 425 N EI Dorado Street City/state►zip Stockton, CA, 95202 C-57 Contractor V&W Drilling,, Inc. License# C57-720904 Phone 209-469-7700 Address 3806 Duck Creek Drive City/State/Zip Stockton, CA 95215 Consultant/Sub-Contractor Condor Earth License# John Lane, PG 6795 Phone 209-234-0518 Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA, 95206 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/W#Is Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑M ON TORNG ❑ HOLLOW S TEM BORING DEPTH —5 feet 08 OLTED TRIFFI C BOX ❑STOVE R PE ❑EXT RACTON(Vap or/Watet ❑ HAMMER/DR VEN Q A OF BOREFO E 2.25 ❑MULTIPLECAS N GS❑MULTI-LEVEL WELL CAS tt DIA g S Q L VAROR PROBE �� ❑ MUD ROTA RY CA$NG THC KNESS�67 TWE OF CAS WG: ❑STEEL 1 PVC ❑ OTHER ❑S 0 L BORNG TW PUSH PO INT(GA CPT) CONDUCTOR CAS PG ❑Y s No Bomg Dia- Casing Dia: C aing Depth: O IN JECT ON(Ar soarae.ozone) ❑ HAND AUG ER GROUT SEAL DEPTH ti31 TREMIE TYPE D FE USED: ❑AUGERS ❑HOSE ❑RPE ❑0 THER ❑ OTHER GROUT SEAL R1 MEED? ❑Yes No (NoteM at mum IF eefall Depth is 30 Ft) WEL U SOIL BORING IDs GROUT SPEC IRC ATONS SVP` :S �2 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #W ELLS TO BE DIST ROYED ❑OVER-BORE DIAMETER of Inches to depth of meet W ELL ID L ❑PRESSURE GROUT To dtp th of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS Ll HOSE U PIPE MUSHROOM OtP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: --76��,rro -V, svP, . hereby certify am authorized to complete this application and thate work one in accordance with Si quln County Ordinance Codes and Standards,and all other applicable Ce Ilfom`ia laws. Signedd�v ' �' (/j�^�-�� Tit(e/Comparf TG> (¢7 4 S Print Name J d C Date f I�7�Z0 r Application Accepted By: Date Issued: Grout Inspection By/Dates: W 113 t`1 /L _L7 Destruction Inspection By/Dates: V L .1,4y_,t4%.Information FA Name / Dir s/Z FA Address L [FA# o(guy 3 PR# FA PE WP Reviewed By Work Plan Date /0 -7 G57 ❑G57 Authorization for Other to Sign Permit orker s Camp ❑Worker's Comp Waiver ElEncroachment Permit ❑Access Agreement ❑Lead Agency Approval IFR COMMENTS/CONDITIONS: ` i _ Q A � � � J� TM 1- WPTfPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DTE WELLPERMIT# INVOICE# Permit2,i3 $152x 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-342 I F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 9 to Mitigation Well Perm t Appl cation